What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for inpatients with Crohn's flare?

DVT Prophylaxis for Patients with Crohn's Flare Inpatient

All hospitalized patients with Crohn's flare should receive pharmacologic thromboprophylaxis with low-molecular-weight heparin (LMWH) unless contraindicated. 1

Rationale and Risk Assessment

Patients with inflammatory bowel disease (IBD), including Crohn's disease, have a significantly elevated risk of venous thromboembolism (VTE):

• 3-4 fold increased risk of VTE compared to the general population 1
• 15-fold increased risk during disease flares 1
• Risk increases to 37.5/1000 patient-years when hospitalized with a flare 1
• Additional risk factors in Crohn's patients include:
  • Immobilization
  • Corticosteroid use
  • Fistulizing or stenosing disease
  • Central venous catheters
  • Recent surgery

Recommended Prophylaxis Regimen

First-line options:

• LMWH (preferred) 1, 2:
  • Enoxaparin 40 mg subcutaneously once daily 1
  • Dalteparin 5000 IU subcutaneously once daily 1

Alternative options:

• Unfractionated heparin (UFH) 5000 U subcutaneously three times daily 1
• Fondaparinux 2.5 mg subcutaneously once daily 1

Duration:

• Continue throughout the entire hospitalization 1

Special Considerations

Renal Impairment

• For patients with severe renal dysfunction (CrCl <30 mL/min):
  • Consider unfractionated heparin due to its shorter half-life and hepatic clearance 1
  • Low-dose fondaparinux (1.5 mg once daily) may be considered, though evidence is limited 3

Bleeding Risk

• For patients at high risk of bleeding:
  • Use mechanical thromboprophylaxis with graduated compression stockings and/or intermittent pneumatic compression 1
  • Note: Rectal bleeding during Crohn's flare is NOT a contraindication to pharmacologic prophylaxis 1

Multidisciplinary Approach

• Patients with Crohn's flare are best managed by a multidisciplinary team including gastroenterologists, surgeons, and pharmacists 1
• Pharmacologic VTE prophylaxis should be part of the standard care protocol for all hospitalized Crohn's patients 1

Pitfalls to Avoid

1. Underutilization of prophylaxis: Despite clear guidelines, studies show that only 39.5% of at-risk medical patients receive appropriate VTE prophylaxis 1

2. Inappropriate withholding due to GI bleeding: Rectal bleeding in Crohn's flare is not a contraindication to pharmacologic prophylaxis 1

3. Delayed initiation: Prophylaxis should be started immediately upon admission, not delayed pending other treatments 1

4. Inadequate duration: Prophylaxis should continue throughout the entire hospitalization 1

5. Failure to recognize high-risk status: Hospitalized Crohn's patients should be considered high-risk for VTE regardless of other risk factors 1

By implementing appropriate DVT prophylaxis for all hospitalized patients with Crohn's flare, the significant morbidity and mortality associated with VTE can be substantially reduced.